Saturday, July 11, 2009

A Better Way to Get a Kidney -

Daniel Asa Rose is the author of "Larry's Kidney: Being the True Story of How I Found Myself in China With My Black-Sheep Cousin and His Mail-Order Bride, Skirting the Law to Get Him a Transplant ... and Save His Life."


So Steve Jobs, the chief executive of Apple, may or may not have jumped to the front of the transplant queue in his quest to get a new liver. What else is new? Wake up and smell the curry, fellow Americans. This is the way the greater world operates.

In China, where my cousin Larry and I went to get him a kidney two summers ago (despite the official Chinese restriction against Westerners doing so), jumping the line is so commonplace as to be unworthy of comment. No one gets angry at a pretty secretary or harried businessman who cuts in front; everyone just takes a half step back and resumes gesticulating on their cellphones. If anything, there's a grudging admiration of such blatant self-advancement.

First come first served, that's the American fantasy. But in fact strength and speed prevail, as they tend to do in other contests. Dog eat dog. Darwinism of the waiting line. Call it what you like, it's not only accepted in most places around the globe, it's expected. No wonder there's so much medical tourism — up to 10 percent of the world's transplant surgery.

In light of this larger reality, may I suggest that we're misdirecting our moral outrage when we take it out on Steve Jobs? It's not the line-jumpers of the world who deserve our indignation — it's the American system that makes us wait in line to begin with, the result of policies that impoverish the supply of organs available for transplant.

Say you need a kidney, the organ most needed the world over. If you sign up today, the wait in most American states will be 5 to 10 years, depending on your underlying medical condition and how suitable a recipient you are.

Seem like a long line ahead of you? You're not imagining it. There are 85,000 people biding their time, most of them on thrice-weekly dialysis that leaves them with an enervated excuse for a life the rest of the time. More than 4,500 of them died last year waiting. On average, that's 13 people dying each day awaiting a kidney.

(Maybe you should hope for liver disease: there are only about 16,000 people on the liver waiting list, and one-third of them get their liver in any one year.)

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Thursday, July 9, 2009

How to Fix Bad Ankles -

Ankles provide a rare opportunity to recreate a seminal medical study in the comfort of your own home. Back in the mid-1960s, a physician, wondering why, after one ankle sprain, his patients so often suffered another, asked the affected patients to stand on their injured leg (after it was no longer sore). Almost invariably, they wobbled badly, flailing out with their arms and having to put their foot down much sooner than people who'd never sprained an ankle. With this simple experiment, the doctor made a critical, if in retrospect, seemingly self-evident discovery. People with bad ankles have bad balance.

Remarkably, that conclusion, published more than 40 years ago, is only now making its way into the treatment of chronically unstable ankles. "I'm not really sure why it's taken so long," says Patrick McKeon, an assistant professor in the Division of Athletic Training at the University of Kentucky. "Maybe because ankles don't get much respect or research money. They're the neglected stepchild of body parts."

At the same time, in sports they're the most commonly injured body part — each year approximately eight million people sprain an ankle. Millions of those will then go on to sprain that same ankle, or their other ankle, in the future. "The recurrence rate for ankle sprains is at least 30 percent," McKeon says, "and depending on what numbers you use, it may be high as 80 percent."

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Wednesday, July 8, 2009

Economic Scene - Health Reform’s Acid Test - Prostate Cancer -

It's become popular to pick your own personal litmus test for health care reform.

For some liberals, reform will be a success only if it includes a new government-run insurance plan to compete with private insurers. For many conservatives, a bill must exclude such a public plan. For others, the crucial issue is how much money Congress spends covering the uninsured.

My litmus test is different. It's the prostate cancer test.

The prostate cancer test will determine whether President Obama and Congress put together a bill that begins to fix the fundamental problem with our medical system: the combination of soaring costs and mediocre results. If they don't, the medical system will remain deeply troubled, no matter what other improvements they make.

The legislative process is still in the early stages, and Washington is likely to squeeze some costs out of the medical system. But the signals coming from Capitol Hill are still worrisome, because Congress has not seemed willing to change the basic economics of health care.

So let's talk about prostate cancer. Right now, men with the most common form — slow-growing, early-stage prostate cancer — can choose from at least five different courses of treatment. The simplest is known as watchful waiting, which means doing nothing unless later tests show the cancer is worsening. More aggressive options include removing the prostate gland or receiving one of several forms of radiation. The latest treatment — proton radiation therapy — involves a proton accelerator that can be as big as a football field.

Some doctors swear by one treatment, others by another. But no one really knows which is best. Rigorous research has been scant. Above all, no serious study has found that the high-technology treatments do better at keeping men healthy and alive. Most die of something else before prostate cancer becomes a problem.

"No therapy has been shown superior to another," an analysis by the RAND Corporation found. Dr. Michael Rawlins, the chairman of a British medical research institute, told me, "We're not sure how good any of these treatments are." When I asked Dr. Daniella Perlroth of Stanford University, who has studied the data, what she would recommend to a family member, she paused. Then she said, "Watchful waiting."

But if the treatments have roughly similar benefits, they have very different prices. Watchful waiting costs just a few thousand dollars, in follow-up doctor visits and tests. Surgery to remove the prostate gland costs about $23,000. A targeted form of radiation, known as I.M.R.T., runs $50,000. Proton radiation therapy often exceeds $100,000.

And in our current fee-for-service medical system — in which doctors and hospitals are paid for how much care they provide, rather than how well they care for their patients — you can probably guess which treatments are becoming more popular: the ones that cost a lot of money.

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Paging Dr. Feelgood. The joys and perils of giving celebrities what they want. Kent Sepkowitz, MD, Slate

Behind every seedy celebrity death stands a seedy celebrity doctor. Or so it surely seems now that Michael Jackson has died under a pharmaceutical cloud of uncertainty. Though we don't know yet just what the autopsy (and inevitable re-autopsy) will show, rumors suggest that investigators searching his residence found painkillers of various shapes and sizes as well as Diprivan (propofol), a powerful anesthetic rarely found outside of ICUs or operating rooms. It's a story we've heard before with Elvis and with the not-really-famous Anna Nicole Smith, whose postmortems both turned up lots and lots of prescription drugs (14 for Elvis, nine for Anna Nicole). Enough drugs, as it turns out, to kill either horse or human.

In these sordid events, the doctor usually starts out in the corner of the story then moves center stage as more and more evidence points to his involvement. Elvis' stay-at-home doctor, George Nichopoulos, M.D., aka Dr. Nick, claimed to have written 10,000 prescriptions in the last seven months of Elvis' life. (Dr. Nick's explanation was that he just "cared too much.") That's not 10,000 pills but rather 10,000 sheets of paper handed or called in to a pharmacist. At an average of, let's say, 20 pills per script, this comes in at about 200,000 pills (or injections), for a chill mean of 1,000 pills a day.*

The story for Anna Nicole Smith, whose autopsy is here and here under her real name of Vickie Lynn Marshall, is more or less the same. First came the downers for sleep, then the uppers to counteract the downers, then the pain meds and the anxiety meds; before you know it, you're talking real pill counts. The problem of dying because of too many, rather than too much, drugs in situ has become so common that it even has gained its own Wikipedia entry under the rubric of "combined drug intoxication."

Of course, not every patient of Dr. Feelgood dies as a result of the easy prescription access. Max Jacobson first copped the nickname for his fine work injecting and medicating JFK as well as Alan Jay Lerner, Marlene Dietrich, and Eddie Fisher. Jacobson had fled Hitler in 1936 and crawled to the top of the heap of celebrity practitioners because of his creative pharmacopeia. One might flatteringly consider him a father of the field of stem cell research: His famous "miracle tissue regenerator" injection contained, among other tidbits, solubilized human placenta as well as amphetamines and pain meds, which left recipients feeling dandy. Despite his extremely happy clientele and fine work ethic (he, too, was said to be a heavy amphetamine user), he eventually lost his license for his shenanigans.

So now are we awaiting the news on poor Michael. His version of Dr. Nick, a physician named Conrad Murray, had, by report, been a member of the retinue for just a few months. Murray's entry into the news was characterized by his apparent attempt to exit the news; he is said to have high-tailed it from the scene of the dead or dying Michael even as police and others descended on the house. His exact contribution to the death will be revealed in the weeks, months, and probably years ahead but is likely to resemble that of his predecessor Dr. Feelgoods—whose pen and syringes and customer-is-always-right attitude ended up creating a corpse where once an icon stood.

In a strange way, I actually stand in awe of these guys. I have taken care of a few celebs in my career, and for me it was an awful experience. If you fuck it up, you're toast. Once I took care of a very important person, a person you have heard of and are very interested in, someone you would be shocked to know had the problem—asthma—that I treated him for. Well, almost treated him for. His complaints and his recollection of near death last time he had the identical symptoms so unnerved me that I asked a colleague to assume his care.

But the Dr. Feelgood experiences no such hesitancy. He isn't like the rest of us in the groveling pack. He steps up when others falter, seizes glory where others panic, moves forward where others second-guess. This is his blessing and his curse. He is everywhere, too—in my own Oklahoma youth, there was a drunken, friendly, not-stupid doctor who worked his way up in local society by giving his special "love potion" injections to the upscale neighborhood's idle doyennes. Though not as accomplished as Drs. Jacobson, Nick, and now Murray, he shared their affliction—a near fatal, groupie-like susceptibility to the powerful seductions of fame. Perhaps it all starts innocently—a rich, famous guy with a tiny problem walks into the office. He can't sleep at night. He's so friendly, sincere, not stuck up like some celebs. Then he comes back a week later because of a sore ankle, wanting a little codeine and bearing an autographed photo or a CD. Other patients notice and figure you must be a pretty good doctor if Mr. Showbiz is coming in. And when his migraines come, followed by the back pain and the sleepiness from the back-pain medicine, you're at the ready to call in a script.

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Tuesday, July 7, 2009

How Does Canada’s Health System Actually Work? - Economix Blog -

OTTAWA — Canadians can be of two minds about their public health care system.

Tommy Douglas, a former premier of Saskatchewan, was voted "The Greatest Canadian" by the Canadian Broadcasting Corporation viewers for setting up what became the model for the country's health system. And a survey last year partly sponsored by the federal government found that Canadians ranked "universal health care" among the 10 defining factors of their country (along with Niagara Falls, beavers, hockey and a robotic space arm).

At the same time, Canadians can be quick to complain about that very system. Their chief complaints include wait times, access to doctors, unusual treatments and specialized imaging equipment as well as its overall cost.

Given that, it's not surprising that Canada's experience is being used to support the arguments of people on both sides of the American debate about health care.

But before judging Canada's system, and its suitability as a model for the United States, let's look at how the system's financing developed.

The biggest problem in assessing Canada is that there are, in fact, 15 different systems rather than a single, national program like Britain's. Each of the 10 provincial and 3 territorial governments administers and delivers health care to most residents. On top of that, the federal government is responsible for native people who live on reserves, as reservations are known in Canada, as well as members of the military and their families.

While broad pieces of federal legislation provide overall guidance for each provincial system, they have nevertheless developed largely on a piecemeal basis since the 1960s. Adding to the complexity is the tendency of provincial governments to bicker amongst themselves while vigorously opposing any federal efforts to usurp their constitutional powers over health care.

So when thinking about health care in Canada, bear in mind that for every general rule there can be a multitude of exceptions.

C. David Naylor, a physician and health policy analyst who is president of the University of Toronto, succinctly summed up the system in the title of a book in 1986: "Private Practice, Public Payment."

Mr. Douglas's socialist government in Saskatchewan introduced Canada's first province-wide, government-financed health care system in 1962, immediately provoking a strike by doctors. But it was a Royal Commission established at roughly the same time that ultimately provided the framework for the rest of the country.

Canada's health care insurance industry, which was growing quickly in the early 1960s, joined with the country's medical association to campaign against publicly funded medical care for all but the poorest Canadians.

The Royal Commission ultimately rebuffed them. Dr. Naylor's analysis is that mixing public coverage with private insurance would be a bureaucratic mess that could cause public monies to subsidize for-profit medicine and insurance.

But the doctors did get some of their demands. Canadian physicians are not government employees. They retain a great deal of control over when, how and where they work. Instead of being paid salaries, most of them bill provincial governments on a fee-for-service basis. Canadian hospitals are also autonomous institutions that are generally, but not necessarily, governed by local health authorities.

The details of how that operates become complicated very quickly. But for patients, it's all invisible.

They never see a bill for hospital treatments or services provided by their doctor. Some hospitals and physicians once imposed surcharges and service fees on patients, but the federal government shut down the practice in 1984 by cutting off health financing to provinces that allowed it. Similarly doctors cannot moonlight and provide basic medical services to patients who are willing to pay for faster or more attentive service.

That doesn't mean, however, that Canadians do not have health care costs that they have to pay out of pocket or through private insurance. Most dental work, prescription drugs for people not at retirement age, and eyeglasses are among the many costs not covered. The Canadian Institute for Health Information estimates that governments covered about 70 percent of the 171.9 billion Canadian dollars (roughly $148 billion) spent on health care last year.

A Doctor by Choice, a Businessman by Necessity -

To meet the expenses of my growing family, I recently started moonlighting at a private medical practice in Queens. On Saturday mornings, I drive past Chinese takeout places and storefronts advertising cheap divorces to a white-shingled office building in a middle-class neighborhood.

I often reflect on how different this job is from my regular one, at an academic medical center on Long Island. For it forces me, again and again, to think about how much money my practice is generating.

A patient comes in with chest pains. It is hard not to order a heart-stress test when the nuclear camera is in the next room. Palpitations? Get a Holter monitor — and throw in an echocardiogram for good measure. It is not easy to ignore reimbursement when prescribing tests, especially in a practice where nearly half the revenue goes to paying overhead.

Few people believed the recent pledge by leaders of the hospital, insurance and drug and device industries to cut billions of dollars in wasteful spending. We've heard it before. Without fundamental changes in health financing, this promise, like the ones before it, will be impossible to fulfill. What one person calls waste, another calls income.

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Monday, July 6, 2009

The First Medicine 2.0 Course

Op-Ed Contributor - Health Care’s Infectious Losses -

HEALTH care reform seems to be on the way, whether we want it or not. So I have been asking questions about the various proposals. Here is a sampling.

Which of the reform proposals will eliminate the millions of infections acquired at hospitals every year?

Which of the proposals will eliminate the annual toll of 300 million medication errors?

Which of the proposals will eliminate pneumonia caused by ventilators?

Which of the proposals will eliminate falls that injure hospital patients?

Which of the proposals will capture even a fraction of the roughly $1 trillion of annual "waste" that is associated with the kinds of process failures that these questions imply?

So far, the answer to each question is "none."

Let's consider that $1 trillion of waste. If we could capture all of it, the savings over 10 years would be five times what President Obama has said he will extract from insurance companies over the same period. The president's vision of bringing down health care inflation by 1.5 percent a year over the next decade would not be a victory, but a capitulation to the enormous waste in the delivery of medical care.

The president says he likes audacious goals. Here is one: ask medical providers to eliminate all hospital-acquired infections within two years. This is hardly pie in the sky: doctors and administrators already know how to do it. It requires scrupulous adherence to simple but profoundly important practices like hand-washing, proper preparation of surgical sites and assiduous care and maintenance of central lines and urinary catheters. With these small steps, we would no longer have the suffering and death associated with infections acquired in hospitals and we would save tens of billions of dollars every year — money we should have in hand before new health-care entitlements are enacted.

What policymakers tend to forget is that only the people who do the work can make this happen. Legislation can't do it, regulation can't do it, infection-control committees can't do it, financial incentives and disincentives can't do it. But excellence is possible, and it has been demonstrated.

Where it works, the common denominators are strong leadership and a committed work force. Among those doctors showing the way are Brent James at Intermountain Health in Utah, Gary Kaplan at Virginia Mason Clinic in Seattle and Richard Shannon at the University of Pennsylvania, who have helped bring infection rates down drastically at their own hospitals and at others.

Hospitals and medical schools have great impetus to increase the ranks of such doctors: these improvements in patient care don't cost money, they save money. And they represent only the tip of the iceberg in opportunities for improving outcomes and reducing costs at the same time.

A next step would be for the government to finance a prompt, detailed and hard-headed study of every example of error, infection and other waste in five major medical centers. Such data would give policymakers and caregivers a clearer picture of the possibilities for cost-saving improvements.

It would also help if reporters and pundits became more informed about the opportunities for improvement, so they could help educate the public and improve the level of the reform debates. As for members of Congress, perhaps it would help them to understand the problem if we assembled the data, by House district, on hospital-acquired infections, medication errors and other waste indicators. They are more likely to push for the right sort of change when they realize that people they know and represent are being hurt or killed by practices we know how to stop.

In the end, any health care reform that does not address the pervasive waste and the associated burden of needless suffering for patients and staff alike will give us little to celebrate.

Paul O'Neill was the secretary of the Treasury from 2001 to 2002.